Stroke/TIA Interdisciplinary Plan of Care

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1 Stroke/TIA Interdisciplinary Plan of Care Patient/family involved in development of plan of care Patient/family agrees with plan of care Patient unable to be involved in plan of care ER and 1st 24 Hours Next 24 hours - Discharge At Discharge Consults Diagnostics Neurology consult Endovascular neurosurgery consult Stat labs, CBC, INR, APTT, urinalysis Stat head CT without contrast CTA, CTP, CXR, EKG Baseline NIH stroke scale PT/OT Speech/dysphagia Rehab Other: Carotid imaging Brain imaging Cerebrovascular imaging Transthoracic Echo Fasting CMP, HgA1c, Fasting lipids, sed rate tpa Intervention Initiate tpa order set (if appropriate) Assess and monitor vital signs, oxygenation, neurochecks and for S/S of bleeding Notify physician of changes Assessments/ Neuro checks Neuro checks every 2 hours 2 then every 4 hours NIH Stroke Scale (completed by physician) Vital Signs Oxygen Baseline NIHSS 2 hrs post-treatment/intervention Vital signs every 4 hrs 24 hours then per unit routine Notify physician if SBP greater than 220 and/or DBP greater than 120 Assess HR and rhythm every shift Maintain flex monitor and report abnormal symptoms One time pulse oximetry. If less than 92% on room air: Initiate oximetry standard of care Initiate Age Specific Standard of Care: Early to Middle Adulthood (18-60) Later Adulthood (61 and above) Assess for changes in neuro baseline If changes, then initiate neuro check flowsheet. Notify physician for further orders 24 hrs post-treatment/intervention For Home O 2, ualify sats via Respiratory Therapy (if applicable) Vital signs and neuro status stable Flex monitor d/c Home O 2 arrangements made (if applicable) IV Site Skin Initiate IV Site Management Standard of Care Assess using Braden tool and initiate appropriate interventions Resolve IV Site Management Standard of Care Elimination Dysphagia Initiate GU Intubation Standard of Care NPO until dysphagia screen Dysphagia screen results: Pass Fail Resolve GU Intubation Standard of Care (11/1/08-1:7)

2 Stroke/TIA Interdisciplinary Plan of Care ER and 1st 24 Hours Next 24 hours - Discharge At Discharge Nutrition If FAIL dysphagia screen, keep patient NPO and consult speech If PASS dysphagia screen, then diet: Diet as tolerated, low animal fat Diabetic 1800 cal Other: Tube feeding Initiate GI Intubation Standard of Care When patient identified with dysphagia, follow recommendations from speech therapist Resolve GI Intubation Standard of Care Patient will tolerate nutrition without aspiration Activity/Safety Medications/ Treatments Anticoagulants/ Antiplatelets Activity: OOB OOB with assistance Other: Turn and position every 2 hours while in bed if unable to move self Monitor fall risk and document interventions per Morse Score IV Heparin Stroke protocol Coumadin Lovenox ASA Plavix Aggrenox Initiate Anticoagulation Standard of Care Monitor tolerance of ordered diet/ supplement. Attend and participate in PT/OT Lipids Lipitor Zocor DVT/ Prophylaxis Ambulating without any assistance Lovenox Coumadin Provide appropriate teaching tool Instruct patient in Lovenox selfadministration and managment of anticoagulants Resolve Anticoagulation Standard of Care Niacin Gemfibrozil Pravachol Other: If patient not ambulating independently by the end of hospital day 2, must initiate DVT prophylaxis Patient/family knowledgeable in anticoagulant and antiplatelet therapy Lab draws arranged Lovenox arrangements completed Patient/family self-administers Lovenox Ensure patient is discharged on lipid lowering agents if LDLgreater than 100, HDL less than 40 or triglycerides greater than 150 SEQs Patient/Family Orient to unit and room Prepare for discharge Review and give pt/family Discharge Teaching Update patient/family about condition Initiate teaching tool and use to Contract Assess learning needs and home instruct patient/caregiver on: situation - Stroke warning signs & symptoms Ensure physician has completed Give patient stroke booklet - Activation of EMS Stroke EBP discharge plan Explain treatments - Personal risk factors & prevention Provide emotional support - Medication Teaching Patient/family able to safely manage Provide patient/family with TV guide - Importance of routine follow up with care at home and instruct to watch stroke-related PCP videos - Disease process - Complications - Safety - Activity Document appropriate discharge instructions on Stroke/TIA discharge contract Give home safety tip sheet (11/1/08-2:7)

3 Stroke/TIA Interdisciplinary Plan of Care Key Patient Outcomes KPO Problem List ER & 1st 24 Hours Next 24 Hours - Discharge At Discharge Discharge Planning Hemodynamics and Arrhythmias Oxygenation Notify Care Coordination Services for - Home Health Referral - placement - rehab/transitional care - medication assistance Patient will be hemodynamically stable as evidenced by SBP less than 220 DBP less than 120 (every shift) Patient in normal sinus rhythm or controlled Afib - (every shift) Adeuate Intake/Output Patient will maintain O2 sat above 92% (every shift) Patient exhibits adeuate pulmonary hygiene as evidenced by (every shift) maintenance of patient airway clear BBS effective cough airway clearance Appropriate referrals/follow-up initiated and completed Safety Complications of Stroke/TIA Knowledge Deficit on Teaching Coping Mechanisms Patient will be free of injury from falls - (every shift) Patient will be free of preventable complications (every shift) thrombophebitis choking/aspiration foot drop Patient will remain free of further brain injury as evidenced by stable or improving neuro status (every shift) Patient and family will verbalize and/or demonstrate knowledge of 1. Stroke warning signs & symptoms 2. Activation of EMS 3. Personal risk factors & prevention 4. Medication teaching 5. Importance of routine follow up with Primary Care Physician Patient and family will demonstrate appropriate coping mechanisms as evidenced by participation in therapy & D/C planning verbalizing & expressing concerns (every day) Nutrition Patient will maintain adeuate nutritional status as evidenced by greater than 75% of meals or via alternative source of nutrition at goal rate (i.e. TPN or tube feedings) Home Patient/family will demonstrate and Patient/family will demonstrate and Maintenance/ verbalize knowledge of: verbalize understanding of all post D/C Planning disease process discharge needs and care complications safety communication/cognition prevention/risk factors medications, as precribed proper home management (11/1/08-3:7)

4 Patient Stamper Hemorrhagic Stroke/Ischemic Stroke/TIA Teaching Tool Upon completion of teaching, patient and/or Learner/Caregiver(s) will demonstrate and/or verbalize knowledge of: Hemorrhagic Stroke Ischemic Stroke TIA Learner Method Educator Learner Method Educator STROKE ESSENTIALS (all videos are on TV channel 16) *Give Stroke Essentials Folder w/booklet and magnet *Stroke Warning Signs and Symptoms *Activation of Emergency Medical Services (EMS)/911 *Importance of Routine Physician follow-up after discharge Review physiology of diagnosis Stroke videos, especially video: Stroke: Reducing the risk *PERSONAL RISK FACTORS FOR PREVENTION AND/OR LIFESTYLE CHANGE (checked box indicates reviewed) High Blood Pressure Smoking Cessation Elevated cholesterol (goal LDL < 100, total cholesterol < 200) Diabetes Management Weight and BMI (obese greater than or eual to 25) Physical Inactivity / Exercise Nutrition / Diet / Alcohol Atrial Fibrillation Carotid Stenosis Illicit drug use (i.e. cocaine) Other: *MEDICATIONS (checked box indicates reviewed) Antiplatelets ( aspirin clopidogrel dipyridamole/aspirin) Anticoagulants ( warfarin heparin enoxaparin) Lipid-lowering medication ( statins other) Diabetic medications Blood Pressure Other *Major components reuired for patient education Learner Codes Teaching Method Codes Pt Patient V Verbal AV Audiovisual Learner (enter initials) W Written D Demo/redemo Caregiver (enter initials) Code 1. Pt, learner, caregiver verbalizes/demonstrates knowledge 2. Needs reinforcement 3. Refused education 4. Education given to member of nursing home, home health or other caregiver staff member Learner/Caregiver Initials Educator Signature Initials Educator Signature Initials (11/1/08-4:7)

5 GENERAL TEACHING TOOL INSTRUCTIONS PURPOSE: The Teaching Tool is an interdisciplinary document used to manually record the teaching that a patient or other learner, receives during the patient s hospitalization. NATURE OF THE FORM: The Teaching Tool is a permanent part of the medical record. It is to be stamped or labeled with patient identification information in the upper right hand corner and completed in black ink. The Teaching Tool may be general (General Medical Teaching Tool or General Surgical Teaching Tool) or specific to a particular patient population or health problem. PERSONS RESPONSIBLE: The registered nurse will initiate the Teaching Tool, most appropriate to the patient s educational needs, after completing the Patient Admission Assessment/Screening Tool. More than one Teaching Tool may be needed for patients with multiple health problems. Example: A CHF patient who is a newly diagnosed Type 2 Diabetic. Other members of the interdisciplinary team will document on the Teaching Tool as well as in discipline specific MIS notes. The registered nurse is responsible to review the Teaching Tool as part of the patient discharge process and complete any incomplete documentation. The MIS discharge contract and Discharge Instruction sheets are used as an additional source of patient education documentation. PLACEMENT IN CHART: The Teaching Tool(s) will be placed as the first item under the Notes Manual tab (lime green) of the chart. Other forms to be placed in order under the Teaching Tool in the Notes Manual Tab are: Teaching Tool Evidenced Based Tool Kit (Preprinted Interdisciplinary Plan of Care (IPC) and Key Patient Outcomes (KPO) Interdisciplinary Plan of Care (MIS care plan - only if needed) Interval Nursing Asssessment(s) Manual Nursing Notes (11/1/08-5:7)

6 Patient Stamper Hemorrhagic Stroke/Ischemic Stroke/TIA Teaching Tool (continued) Upon completion of teaching, patient and/or Learner/Caregiver(s) will demonstrate and/or verbalize knowledge of: Hemorrhagic Stroke Ischemic Stroke TIA Learner Method Educator Learner Method Educator SAFETY (checked box indicates reviewed) Fall prevention Decreased sensation Spatial/perceptual awareness Other ACTIVITY (checked box indicates reviewed) Mobility Transfers ADLs Medical euipment/assistive devices Other TESTS/PROCEDURES (checked box indicates reviewed) CT scan CT angiogram MRI MRA EKG Echocardiogram Carotid Ultrasound Trans-esophageal echocardiogram (TEE) Flex Dysphagia Screen STROKE RELATED COMPLICATIONS (checked box indicates reviewed) Aphasia Communication/speech issues Plegia / paresis Dysphagia Subluxation of shoulder Neglect Incontinence DVT prophylaxis / prevention Active DVT UNIT ROUTINE *Major components reuired for patient education Learner Codes Teaching Method Codes Pt Patient V Verbal AV Audiovisual Learner (enter initials) W Written D Demo/redemo Caregiver (enter initials) Code 1. Pt, learner, caregiver verbalizes/demonstrates knowledge 2. Needs reinforcement 3. Refused education 4. Education given to member of nursing home, home health or other caregiver staff member Learner/Caregiver Initials Educator Signature Initials Educator Signature Initials (11/1/08-6:7) 5:7)

7 SPECIAL INSTRUCTIONS: 1. Content to be taught is found in the left-hand columns of the form. All specified items must be addressed with an evaluation code prior to patient discharge. 2. Only one signature/evaluation is reuired in the first column to indicate that you have taught more than one topic under the teaching category. Where indicated, you must check appropriate boxes for specific topics that you reviewed with the patient/caregiver/learner. The comment boxes in this column allow you to add comments about the teaching you have done. For example, you could write, Reinforce a fib teaching with patient, so others will know that this needs reviewed with the learner. 3. The second column on the right allows you to document any re-education done or to address a single topic later, such as a test that was ordered after the initial education was done. reinforce education, if needed, with one learner (a return session) record teaching of more than one person for the same item 4. Learning column: The code (Pt) is used when the patient is taught. If someone else is taught, on behalf of the patient, record the persons name as the Caregiver(s)/Learner(s) and the person s initials in the lower left box. Note: the learner does not need to sign the form. Those initials are used in the learner column to indicate who was taught. 5. Method column: Use the Teaching Method codes, found at the bottom of the form, to indicate how the education was presented to the learner. 6. column: Mark the month and date of the education. 7. column: Use the evaluation codes, found at the botom of the form, to indicated the response to education or why education was not given. 1 = Learner has shown by demonstration or verbalization that the material is understood. No further teaching needed. 2 = Learner needs to have the content reviewed again: more teaching is needed for learner to fully grasp the material a re-demo is needed, to assure proper techniue is mastered 3 = Learner refuses to receive instruction or educational materials 4 = Learner is a professional staff member from a nursing home, home health agency that will be following patient, or other caregiver staff member (11/1/08-7:7)

8 RN Dysphagia Screen for Stroke EBP If YES to ANY uestion or part below: keep patient NPO, notify attending physician and obtain Dysphagia consult. Part 1: YES NO Does the patient exhibit Decreased consciousness any of the following? Facial weakness If NO to all, proceed to part 2. Tongue weakness Weak or absent cough Poor or absent voice Dysarthria (Slurred speech) Unable to follow simple commands Inability to handle own secretions G tube/j tube with current NPO status PART 2: PATIENT MUST BE SITTING UPRIGHT AT 90 Ask patient to take a sip of water from a cup (no straw) ANY changes to voice uality (wetness, gurgling) and/or coughing; drooling, oral holding, change in breathing, watery eyes, runny nose, delayed coughing, throat clearing or no swallow reflex? YES? STOP. Keep patient NPO NO? Safe for oral intake. If NO to ALL parts, it is safe to give the patient oral intake. The patient was screened prior to any oral intake. Completed By: /Time: Unit: (11/1/08-8:7) 6:7)

9 Order Sheet & Progress Record USE BLACK BALLPOINT INK ONLY STROKE EBP DISCHARGE PLAN DATE PROGRESS RECORD DATE MEDICATIONS DIETS TREATMENTS LAB TESTS Discharge on antiplatelets? Yes No If YES, antiplatelet ordered > If NO, document contraindication: Discharge on Lipid Reducer? Yes No If YES, Lipid Reducing Agent ordered > LDL = LDL goal less than 100 mg/dl Low cholesterol/low fat diet ordered? > If NO, document contraindication Atrial Fibrillation this admission or history of? Yes No If YES, coumadin ordered? > Follow up lab work ordered? > If NO, document contraindication Is patient a smoker? Yes No If YES, smoking cessation advice given? Yes No If YES, smoking cessation medication ordered? > Was Rehab ordered for patient? Yes No If NO, please document reason(s): Does patient have Diabetes? Yes No If YES, diabetic medication(s) ordered > If YES, diabetic diet ordered > Physician Signature (11/1/08-9:7) 7:7)

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